200 years of American medicine (1776-1976) ..

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE • Public Health Service • National Institutes of Health

200 YEARS

of American Medicine
(1776 - 1976)

NATIONAL LIBRARY
OF MEDICINE

8600 Rockville Pike
Bethesda, Md. 20014

Cover:

Title page from Dr. John Jones' Plain
Concise Practical Remarks on the
Treatment of Wounds and Fractures,
1775. This was the first full-length
medical book written by an American
and published in this country.

200 YEARS
of American Medicine

(1776 -1976)

In recognition of the nation's bicentennial, the
National Library of Medicine is presenting an
exhibit honoring selected American achievements
in medical science and practice and outlining the
development of medical education, medical
literature, and public health in the United States.
Themes of the exhibit are described in the following
pages.

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service
National Institutes of Health

DHEW Publication No. (NIH) 76-1069

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Physicians

and the Revolution

Many American physicians played an
important role, both politically and
professionally, in the winning of American
independence.

A decade in advance, John Morgan
expressed the feelings of many young men
when in 1766 he warned against oppression of
American liberties. Morgan later became
Director General of the medical department
of the Continental Army. Joseph Warren of
Boston was a leading figure in patriotic circles
that included Samuel Adams and John
Hancock. He was killed at the Battle of Bunker
Hill. Benjamin Rush, one of the most
prominent American physicians of his day
and three other physicians signed the
Declaration of Independence. Immigrants,
like Bodo Otto from Germany, and young
men later to become leaders of the
profession, like James Thacher and James

Tilton, also supported the American cause.

Regrettably, the colonies' leading
physicians were often a quarrelsome lot, and
the history of their service is marred by the
bitter feud between Morgan and his
successor William Shippen. Nevertheless,
Morgan and Rush found time to issue
pamphlets on military medical problems,
while others issued more substantial works
like John Jones on military surgery and
William Brown's pharmacopoeia.

Two major European nations were also
active in the fighting; our ally France and our
enemy England. Both had comparatively well
developed military medical services, the
French under their distinguished physician-
in-chief, Jean Francois Coste. British accounts
suggest that their record for maintaining the
health of the troops was considerably in
advance of the Americans'.

On the preceding page is reproduced a letter from
George Washington to "The Honorable Joseph Jones
Esq. of Congress at Philadelphia." The original is in the
collection of the National Library of Medicine's History of
Medicine Division. The text follows.

Head Quarters Sep. 9th, 1780

Dear Sir:

I have heard that a new arrangement is about to take
place in the Medical Department, and that it is likely, it
will be a good deal curtailed with respect to its present
appointments.

Who will be the persons generally employed I am not
informed, nor do I wish to know; however I will mention

to you, that I think Doctors Craik and Cochran from their
services, abilities and experience, and their close
attention, have the strictest claim to their country's
notice, and to be among the first officers in the
establishment.

There are many other deserving characters in the
medical I ine of the army, but the reasons for my
mentioning the above gentlemen are, that I have the
highest opinion of them, and have had it hinted to me
that the new arrangement might possibly be influenced
by a spirit of party out of doors [i.e., partisan politics],
which would not operate in their favor. I will add no more
than that I am

With the most perfect respect
Dear Sir
Your most obedient servant
C. Washington

Medical Education

With the achievement of political
independence, Americans still had far to go to
reach an equal degree of intellectual and
cultural independence. Still heavily
dependent on Europe, American physicians
had made only slight beginnings in the
development of American institutions. One
of the first needs was the capability of
educating physicians in our own country.

Before the Revolution, practitioners were
trained chiefly by apprenticeship; a few who
could afford the time and expense traveled
abroad for further education. In 1765, John
Morgan and William Shippen of Philadelphia,
both graduates of Edinburgh, founded the
first medical school in the country, now part
of the University of Pennsylvania. Additional
medical schools were founded at Kings
College (now Columbia University) in 1768
and at Harvard in 1783. In the 19th century,
however, groups of physicians throughout
the country began founding small proprietary
medical colleges, dividing among themselves
the lectures and student fees. Entrance and
graduation requirements were sufficiently
low to insure a steady income. Laboratory and
clinical facilities were woefully inadequate.
Large numbers of poorly trained physicians
were released to practice on the public.

As a result, the abler and more ambitious
students continued going to Europe. Early in
the 19th century Paris hospitals were the
major attraction; after the Civil War,
Americans flocked to Austrian and German
universities, some to learn a clinical specialty,
others the basic sciences. As increasing
numbers returned with an awareness of good

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teaching and above all of the possibility of
transforming both teaching and practice
through close association with research,
scientific medicine began to evolve in this
country.

Reforms were also being instituted by
educational leaders from outside the medical
profession. In the 1870s President Charles
Eliot of Harvard introduced a graded
curriculum into the medical school,
lengthened the course from two to three
years, elevated the entrance requirements,
and substituted part-time salaries paid by the
university for direct payment from student
fees.

Under the educational leadership of Daniel
Coit Gilman, the new Johns Hopkins
University in Baltimore emphasized graduate
education in research. The medical school,
opening in 1893, was conceived as part of the
university and closely integrated with the
Johns Hopkins Hospital. In addition to
upgrading undergraduate medical
education, the Hopkins originated the
residency training system.

Public and professional concern for
medical education culminated in a survey of
all the medical schools by Abraham Flexner
under the auspices of the AMA Council on
Medical Education and the Carnegie
Foundation for the Advancement of
Teaching. His report, Medical Education in
the United States and Canada (1910), had
immediate and far-reaching impact. There
were then 131 medical schools in the United
States, most of them proprietary. By 1920, 46
had closed or were absorbed by stronger
institutions. Others were strengthened by
merger, by university affiliation, and by the
infusion of support from private foundations
and state governments.

By the 1920s the four years of medical
school were compartmentalized into two
years of basic sciences taught by discipline
and two years of clinical training. Since the
1950s increasing emphasis has been placed on
teaching basic concepts in a program planned
by interdisciplinary subject committees and
tailored, in part, to the individual student's
interest.

An important factor in recent changes is
the growth of federal support for medical
research, mostly in medical schools, from $27
million in 1947 to $1.4 billion in 1966. In 1968-
69 approximately one third of faculty salaries
were paid from federal sources. The impact of
this federal support was generally favorable
although some critics claim that
concentration on research has diverted
faculties from their primary mission of
developing physicians. The present decrease
in federal support, the abundance of
specialists, and the shortage of primary-care
physicians seem to assure continuing
modifications in American medical
education.

Abraham Flexner (1866-1959)

William H. Welch (1850-1934)

Medical Literature

Closely linked to the development of
medical education, and equally important for
the advance of medicine in this country, was
the growth of suitable means for recording
and disseminating new medical ideas and
information.

The first purely medical publication in this
country was a broadside by the Reverend
Thomas Thacher, A Brief Rule to Guide the
Common People of New-England How to
Order Themselves and Theirs in the Small
Pocks or Measels, Boston, 1678. Most colonial
medical publications were pamphlets.
Physicians who wished to publish scientific
observations generally submitted them to an
English journal.

The first American medical journal, The
Medical Respository, was started in New York
in 1797. In the half century following, the
number gradually grew. Monographs also
appeared in increasing profusion, although
most of the best ones were reprints and
translations of books published abroad. In
1848 the Committee on Medical Literature of
the AMA, chaired by Oliver Wendell Holmes,
identified twenty American medical journals.
With rare exceptions, such as the American

Journal of the Medical Sciences, the
Committee found them wanting and stressed
the need for more conscientious editing and
the elimination of unworthy articles and
parasitical authorship. Similar criticisms were
leveled at monographs.

The quality of American medical literature
markedly improved with the growth of
scientific medicine in the late 19th century. As
physicians returned from graduate training in
Austria and Germany, their reports of clinical
and laboratory research upgraded existing
journals and created a need for new ones
devoted to the specialties. One of the earliest
was the Journal of Experimental Medicine,
established in 1896.

In the 20th century the tables turned.
American texts are translated into foreign
languages. The number of journals of
biomedical interest has grown in 100 years
from less than 50 to more than 700.
Improvements in medical education, the
growth of medical specialties, and the
continuing expansion of basic research have
placed the American medical literature in a
position of primary world importance.

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Public Health

In the application of medical knowledge,
public health organizations have played a
vital role in improving the health of the
nation.

Most early public health activities were
conducted on a part-time basis at city, town,
and village levels. However, in 1850 Lemuel
Shattuck urged Massachusetts to form a state
board of health to encourage and coordinate
local efforts. When finally established in 1869,
the Massachusetts State Board of Health
became the model for other state health
departments.

By mid-century also, recurring cholera and
yellow fever epidemics indicated a need for
coordinating sanitary measures among the
states. The National Board of Health,
established in 1879, was an early effort to
provide the Federal Government with on-
going professional advice on these and other
health matters, but its ambitions for an
extensive national health role were
premature. Such a role eventually fell to the

United States Public Health Service after a
gradual evolution.

Under the Art for the Relief of Sick and
Disabled Seamen passed in 1798, a chain of
marine hospitals at inland and coastal ports
gradually emerged under the loose direction
of the Treasury Department. In 1871 the
Department brought them under the
centralized control of a Supervising Surgeon,
later renamed the Surgeon General. The
Marine Hospital Service thus created
gradually took over quarantine
administration, the control of vaccines,
epidemiological investigation, and other
health-related functions. By 1912theagency's
growing scope was reflected in its present
name, the Public Health Service. During the
1930s the Hygienic Laboratory, an outgrowth
of bacteriological studies conducted during
the mid-1880s by Joseph J. Kinyoun at the
Marine Hospital on Staten Island, becamethe
National Institute of Health, located at
Bethesda, Maryland.

Supplementing governmental efforts,
laymen and physicians have organized to
promote research, education, legislation, and
improved methods. The American Public
Health Association and other professional
societies were established in the 1870s and
later. The Pennsylvania Society for the
Prevention of Tuberculosis, established in
1892, provided the model for other voluntary
associations aimed at this and other specific

health problems. Similarly, wealthy
individuals have supported public health
through the Russell Sage, Kellogg, Milbank
and other foundations. The Rockefeller
Sanitary Commission carried out a far-
reaching anti-hookworm campaign in the
South from 1909-1914. The Rockefeller
Foundation has supported sanitary work in
foreign countries and financed the first
American schools of public health.

Another area of public health concern for
at least 150 years has been the improvement
and expansion of vital statistics. Even before
the Civil War, the American Medical
Association and others promoted state
registration and the federal census began
collecting vital statistics. Following
improvements introduced by John Shaw
Billings in 1880 and 1890, a permanent Census
Bureau was created in 1902.

As mid-19th century statistics showed the
correlation of high mortality rates with filthy
conditions, the specialty of sanitary
engineering emerged after the Civil War to
help provide adequate sewer and water
systems, and to organize urban street
cleaning and garbage removal. George E.
Waring, a pioneer in this field, dramatized
public sanitation by putting New York's street
cleaners into white uniforms, thus earning
them the sobriquet of "white wings."

After 1880 bacteriology transformed public
health activity. Particularly important pioneer
applications were made by scientists of the
Army and the Department of Agriculture and
by health officials in Rhode Island, Michigan,
and New York. Scientific Bulletin No. 7 of the
New York City bacteriological laboratory
marked the beginning of laboratory diagnosis
as a routine procedure in the control of
infectious diseases.

Preventive medicine goes back to the
introduction of smallpox innoculation by
Cotton Mather and Zabdiel Boylston in
Boston in 1721. After 1800 it was replaced by
the more effective and less dangerous
Jennerian vaccination. With the development
of bacteriology, European discoveries such as
Pasteur's rabies treatment, diphtheria
antitoxin, and typhoid vaccination were
quickly introduced into the United States.
Thereafter, progress in immunology was

slow; by World War 1 1 it was overshadowed by
new drugs, especially penicillin. The
introduction of polio vaccine in the 1950s,
following a massive research effort, was thus a
thrilling public and scientific event. Recent
decades have also seen important progress in
immunization against influenza, measles,
allergies, and other diseases.

Other public health specialties have also
developed. Although Benjamin M'Cready
had made a general survey of the health
factors in different American occupations as
early as 1837, Alice Hamilton still felt in 1910
that she was entering industrial medicine "as
a pioneer into a new, unexplored field."
Dental public health has also come of age, its
most notable achievement, albeit a highly
controversial one in some communities,
being the fluoridation of public water
supplies to reduce dental caries.

Alice Hamilton (1869-1970)

Scientific Contributions

Changes in medical education and the growth of medical literature formed essential institutional
bases for the increasing number of contributions to knowledge by American physicians, scientists,
and other health professionals and for their increasing ability to care for their patients. A few have
been selected by way of illustration; many others are equally deserving.

— J. Marion Simms (1813-1883), for contributions to gynecology.

— William T. G. Morton (1819-1868), for surgical anesthesia.

— S. Weir Mitchell (1829-1914), for work in clinical neurology.

— Joseph Leidy (1823-1891), for contributions to paleontology.

— Abraham Jacobi (1830-1919), for establishing pediatrics as a specialty.

— Joseph J. Woodward (1833-1884), for contributions to microscopy and photomicrography.

— Mary Adelaide Nutting (1858-1948), for raising the standards of nursing.

— Harvey W. Wiley (1844-1930), for his campaigns against food adulteration.

— William H. Welch (1850-1934), for his major role in introducing scientificmedicinetothe U.S.

— John J. Abel (1857-1938), for the isolation of epinephrine andearly studies in plasmapheresis.

— Theobold H. Smith (1859-1934), for demonstrating the tick transmission of Texas cattle fever.

— Walter Reed (1851-1902), for studies on yellow fever.

— Thomas Hunt Morgan (1866-1945), for the chromosome theory.

— Charles Wardell Stiles (1867-1941), for solving the problem of hookworm disease.

— Alice Hamilton (1869-1970), for work in industrial medicine.

— Walter B. Cannon (1871-1945), for studies of the autonomic nervous system.

— Eugene L. Opie (1873-1971), for contributions to the pathology of diabetes mellitus and
tuberculosis.

— Florence R. Sabin (1871-1953), for research in neuroanatomy and embryology.

— Joseph Goldberger (1874-1929), for demonstrating the role of dietary deficiency in pellagra.

— Oswald T. Avery (1877-1955), for work with the transforming factor in pneumococci-DNA.

Michael M. Davis (1879-1971), for efforts to improve health care delivery.

Donald D. Van Slyke (1883-1971), for studies on acid-base balance and the gas and electrolyte
equilibria in the blood.

Paul R. Hawley (1891-1964) and Paul B. Magnuson (1884-1968), for improving medical care for
veterans.

Richard H. Shryock (1893-1927), for studies in the social history of medicine.
Alfred Blalock (1899-1964), for work on shock and contributions to cardiac surgery.
Percy L. Julian (1899-1975), for work in steroid chemistry.

Charles R. Drew (1904-1950), for studies on blood plasma and blood preservation.
John H. Gibbon (1904-1973), for developing the heart-lung machine.

Silas Weir Mitchell
(1829-1914), shown
in his clinic at the
Infirmary for Nervous
Disease in Philadelphia.

Mary Adelaide Nutting
(1858-1948), leading
figure in U.S. nursing
education.

Joseph Goldberger
(1874-1929), member of
the U.S. Public Health
Service who conducted
innovative experiments
in the study of pellagra.

Charles R. Drew (1904-
1950), leading
researcher in the study
of blood plasma and
blood preservation.

National Library

During the past century of outstanding
progress in medicine and public health, the
National Library of Medicine has continued
to play an important role in making new
knowledge more readily available.

The Library has descended from a small
collection of books begun by Surgeon
General Joseph Lovell about 1818. As the
years passed, it grew slowly; in 1840 a clerk
wrote the titles — about 200 altogether — in a
little notebook that he titled grandly, "A
catalogue of books in the library of the
Surgeon General's Office, Washington City."
The collection continued to expand at a
modest pace until 1871, when the decision
was made to develop it into the "National
Medical Library." This, to the Surgeon
General and his staff, meant a collection that
contained every medical book published in
the United States, and as many as possible of
all other publications relating to medicine
and allied sciences. Assistant Surgeon John
Shaw Billings was given the responsibility for
carrying out this decision.

Billings, who had been managing the
library since 1865, greatly accelerated the
collecting of all medical publications. He
sought new and old books, American and
foreign periodicals, reports of civilian and
military health organizations, dissertations,
pamphlets, manuscripts, portraits and prints.
He purchased from booksellers and
physicians, exchanged duplicates with
individuals and with other libraries, and

Surgeon General Joseph Lovell (1788-
1836)

persuaded physicians, institutions, editors,
and publishers todonate publications. Within
a few years Billings had acquired practically
every issue of every medical journal ever
published in the United States and Canada,
and 75 per cent of all medical periodicals ever
published throughout the world. By 1875 the
library was already more than twice as large as
the next largest American medical library.

With this resource at his command, Billings
conceived and established medical
bibliographies of importance to physicians
throughout the world. In 1879 he founded the
monthly Index Medicus, published
commercially under the editorship of his
colleague Robert Fletcher. In 1880 he brought
out the first volume of the Index-Catalogue of
the Library of the Surgeon-General's Office, a
monumental work that made the Library
internationally famous. For three-quarters of
a century volumes continued to appear, 61 in
all, until it was superseded by more rapid
indexes in the 1960s.

After Billings retired in 1895, the librarian's

John Shaw Billings (1838-1913)

of Medicine

chair was occupied by a succession of medical
officers, among them Walter Reed. The
Library building on the Mall, opened in 1887,
soon became gorged with material. Within 25
years librarians were asking for more space,
but wars, depressions, and priorities kept the
Library in its increasingly obsolescent
structure. Finally, in 1956 Congress passed a
law formally establishing the Library as the
National Library of Medicine, transferring it
to the Public Health Service, and providing
for a new building. In 1962 the Library moved
from Washington to its new home adjacent to
the National Institutes of Health.

Because of the great increase in medical
publication starting in the late 1940s and the
demands for faster bibliographic service, the
Library turned to new technologies in the
1950s to speed the availability of indexes and
the transmission of data to users. A partially
mechanized publications system was
introduced in 1960 to produce Index
Medicus, only to be superseded four years
later by a computerized system named

Library building on the mall, opened in
1887.

MEDLARS (MEDical Literature Analysis and
Retrieval System). In the 1970s, using
MEDLARS and other data bases, the Library
developed MEDLINE and a number of other
nationwide on-line bibliographic retrieval
systems. To speed service to medical
researchers, educators, and practitioners, the
Library provided leadership and funding for
the development of a network of regional
medical libraries. Congress gave the Library
authority to bestow grants-in-aid and
established the Lister Hill National Center for
Biomedical Communications to apply
advanced technology to the dissemination of
medical information.

A century and a half after its birth the
Library has grown from a few books on the
shelf of a room in Washington to a collection
of more than a million publications, the
largest medical library intheworld, operating
one of the world's largest bibliographic
information retrieval systems. Its services are
known and used throughout the world.

Below: The National Library of
Medicine's present building, completed
in 1962.

Right: MEDLINE terminal. MEDLINE
(MEDLARS-On-Line) is the library's
computerized data base.

Images of the

American

Physician

Pictures of physicians, other than formal
portraits, have tended to fall into one of two
groups: the kindly "family doctor," or the
caricature.

The "family doctor" concept is usually
visualized as a one-to-one relationship in a
simple setting between a compassionate
doctor and a worried but hopeful patient,
often with family. It has been repeatedly
impressed on the American consciousness by
magazine art, such as that of the skillful
illustrator Norman Rockwell, by advertising,
and by movies.

Caricature, on the other hand, has
traditionally lampooned not only medical
men but alsoquacksand patients. In America,
medical caricature has been largely confined
to magazine and newspaper cartoons.
Recently it has been appearing in fine prints
by contemporary American artists and seems
to express a growing concern with perceived
depersonalization and increasing costs of
medical care. As America moves into its third
century, these views of sensitive observers
reflect some of the serious social problems
facing medicine in the years ahead.

DHEW Publication No. (NIH) 76 -1069